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<meta name="description" content="患者性别：男患者年龄：45简要病史：患者三个月前在我科龈上洁治时发现36牙合面有浅龋坏，接受医生建议充填治疗。术后一直有咬合不适症状，无自发痛，夜间痛，冷热刺激痛。两个月前到我科复诊，无缓解。患者是另一位医生看的，他离职了，我从此接手。体格检查：检查充填体完好，无叩痛，无松动，粘膜无异常。冷诊同对照牙，咬诊不适。辅助检查：摄片发现龋坏处离髓腔尚较远，根尖区未见异常。临床诊断：36牙本质敏感。治疗经">
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        <p>患者性别：男<br>患者年龄：45<br>简要病史：患者三个月前在我科龈上洁治时发现36牙合面有浅龋坏，接受医生建议充填治疗。术后一直有咬合不适症状，无自发痛，夜间痛，冷热刺激痛。两个月前到我科复诊，无缓解。<br>患者是另一位医生看的，他离职了，我从此接手。<br>体格检查：检查充填体完好，无叩痛，无松动，粘膜无异常。冷诊同对照牙，咬诊不适。<br>辅助检查：摄片发现龋坏处离髓腔尚较远，根尖区未见异常。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0001-szcthyht/01.jpg"><br>临床诊断：36牙本质敏感。<br>治疗经过：与患者沟通后，去除原有充填体，未发现继发龋，洞底有一点颜色较深，探诊洞底敏感。丁氧膏安抚半月，诉症状消失，去除安抚物，TheraCal LC垫底，SE-Bond，VoCo复合树脂充填。<br>半个月后患者来就诊，诉上次治疗后一直有咬合不适症状，同前。于是去除充填物及垫底物，洞底涂布司迈尔牙齿脱敏剂，玻璃离子暂充观察半月。<br>后患者来复诊，主诉咬物时仍然有不适感，但无冷热刺激痛、自发痛。检查暂充物完好，按压充填物时患者有不适感。去除暂充物，去除时患者较敏感。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0001-szcthyht/02.png"><br>去除暂充物后的情况，画圆圈的区域是探诊比较敏感的地方。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0001-szcthyht/03.png"><br>咬了个蜡，洞底用光固化氢氧化钙垫底。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0001-szcthyht/04.png"><br>树脂充填，调合以后。对颌近腭尖正好对着充填体，磨耗比较厉害，但是不敢调。<br>后来患者又反复来了几次，都是拆了安抚，症状缓解，再补。都没有收费。最后患者自己放弃了，说就这么着吧。<br>这是我两年前的病例了，当时还在丁香园上发帖请教网友，但是一直无解。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0001-szcthyht/05.png"><br>最近换了工作单位，进行了一个月的岗前培训，感觉收获蛮大。最主要还不是在技术上，而是一些想法上。干这行真的要一辈子不停学习，不然就会落伍。新单位每天早上要开晨会，我打算讲这个病例。看了一下粘接方面的书。<br>主要是参考这本<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0001-szcthyht/06.png"><br>粘接力是粘接剂与被粘物表面之间的连续作用力或结合力，它包括机械嵌合力，分子间力(范德华力和氢键)和化学键力。<br>牙釉质和树脂之间的粘接技术较成熟，可以达到较高的粘接强度。牙本质的树脂粘接强度低于牙釉质。修复性牙本质(硬化牙本质)的粘接强度明显下降。根管内壁牙本质，粘接前要彻底清除根充糊剂，并用乙醇和水反复冲洗，在粘接前应干燥根管。牙骨质，临床上无更好的粘接方法。<br>粘接力的获得:<br>       * 粘接剂与被粘接物的相互吸附力；<br>       * 粘接剂之间的化学结合；<br>       * 粘接剂和不平的被粘物表面的机械嵌合力；<br>       * 牙本质和树脂层之间形成的混合层并产生化学结合；<br>       * 金属表面形成作用膜和树脂的化学结合；<br>       * 瓷表面通过偶联剂和树脂发生化学结合。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0001-szcthyht/07.png"><br>树脂粘接材料:<br>①经典牙釉质粘接剂:双甲基丙烯酸酯。<br>②牙本质处理液:去除玷污层，表面改性。<br>③牙本质表面预处理剂:改变牙本质表面，使亲水性牙本质与疏水性树脂更容易结合。<br>④粘接剂:有一定粘稠性的流动树脂，可渗入牙本质胶原纤维网并在其中固化。<br>树脂粘接剂与牙釉质的粘接机制:机械嵌合。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0001-szcthyht/08.png"><br>与牙本质的粘接机制:形成混合层。清除玷污层，牙本质脱矿，形成三维牙本质胶原网络，用处理剂增强表面润湿性，树脂渗入胶原网络并固化，形成树脂增强牙本质层，即混合层，厚度2-10μm，这是牙本质粘接的关键。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0001-szcthyht/09.png"><br>我这个病例，可能就是去除玷污层，暴露牙本质小管后，后面的预处理和粘接没做好，导致粘接失败，牙本质小管仍然暴露，充填体是有轻微移动的，一移动刺激牙本质小管内的小管液，导致敏感疼痛了。<br>树脂粘接剂的发展：<br>初期：酸蚀剂和粘接剂，只酸蚀釉质。<br>1978：酸蚀牙釉质和牙本质，才有粘接性树脂单体。酸蚀后的冲洗和吹干，会使胶原纤维网的空间缩小，影响粘接力。酸蚀后，涂抹以HEMA为主要成分的预处理剂（primer），使收缩的胶原纤维再度湿润膨胀。但效果仍不好。用湿粘接方法，酸蚀冲洗后，并不完全吹干牙面，直接涂抹粘接剂或预处理剂，可多次涂抹，但因水分残留，长期耐久粘接性能低下。<br>九十年代，出现自酸蚀粘接剂，用含有酸性基团的预处理剂处理，即可产生自酸蚀的效果，不是去除玷污层，而是对其改性。它使酸蚀和冲洗变得不必要，简化了操作。<br>分代：前三代，粉液调和化学固化。第四代，开始真正的粘接时代。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0001-szcthyht/10.png"><br>可见并不是越新的粘接剂就粘得越牢，只是操作越来越简便了。要根据临床需要选择合适的粘接剂。<br>关于粘接剂的分代，以前我是不太清楚的，就知道看别人怎么做，说明书怎么说，然后照着做，至于为什么这么做没有去深究。这次是在入职培训的时候一位带教老师问我这个问题，我答不上来，他才跟我说要看书。今后一定加强学习，努力争取赶上吧。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/other/wx.jpg"></p>

      
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